Accessing treatment for eating disorders requires bravery and is very challenging financially, emotionally, physically and spiritually. Most ED professionals know that the fears of judgment and change are major barriers to clients making their way into our programs and offices. We also know that the antidote for fear is a safe environment where a client can open up and not receive condemnation for thoughts, feelings, and behaviors that have already isolated them from others in their lives. There are many clients who never make it through the treatment door due to perceived microaggressions from the start. Other clients encounter microaggressions from providers or other clients that curtail progress if the client is not practiced in skills including confrontation, self-love, pride, and self-expression. The underlying risk factors for EDs that we address in treatment must include the historical and current marginalization and cultural trauma in our clients’ lives and how this status may be a strong part of the etiology of their symptoms. It is the responsibility of providers to ensure this trauma is not replicated or reinforced in the treatment setting. Our marginalized clients arrive with intergenerational fears that they do not have control over what has happened or could happen to their bodies. This very robust reason to have Body Image Issues and Eating Disorders to manage the ongoing trauma must be examined in therapy.

According to Dr. D.W. Sue (2010), microaggressions are “insults, slights” and physical actions that come in many forms and range from assault to insult, can be intentional or unintentional, and deny or challenge the experiences of the person you are speaking with or about. Microaggressions can be cloaked in a veil of deniability as the speaker/actor can fall back on ignorance or surprise that their statement engendered hurt feelings. These types of microaggressions can also be easily denied or laughed off by onlookers as the recipient’s hypersensitivity. How facile it is to fall back on ignorance when another person is hurt by a comment. Someone not knowing they said anything hurtful does not change the fact that many people experience these slights daily and that the harm that comes from these insults/assaults exists. Common everyday examples cited in the literature include asking a LatinX person where they are from or a white woman holding her purse closer when passing a person of color. Assisting someone who is using a wheelchair when they have not asked for help is another commonly reported example. Clients may be experiencing these microaggressions due to their gender, socio-economic status, race, age, sexual preferences, ability, and religion on a regular basis and not even know where to begin to fix how that harms. I have witnessed a friend of mine be called “sir” many times despite her self-identification as a cis-gendered, gay woman.

As clinicians, we need to be clear where our own biases lie regarding gender, sexuality, race, ability, age, and religion and how that manifests in our work. We need to be aware of looking out of our own “cultural eyes” and biases when we encounter someone who is in a marginalized group or is different from oneself. I write this article as a white, Jewish, and lesbian practitioner. You, the reader, have your own nuanced and intersectional identities layered with oppression and privilege. As clinicians, of course we cannot override implicit bias overnight, but it is our duty to work actively against it. The antidote is to develop cultural humility. Tervalon and Murray-Garcia (1998) and Hunt (2001) define cultural competency as rooted “…in cultural humility, which involves a continual process of reflection of one’s values and biases”. The goal according to Hunt, is not “cultural competence,” because that can be a risky endeavor as culture is not static. Instead, each clinical encounter must be followed by intentional self-reflection about one’s reactions, feelings, beliefs, assumptions, and values. The ultimate goal is self-awareness, and respect and recognition of each individual’s cultural values within the therapeutic dyad, as well as to understand that the chronic stress brought on by cultural stress is real and in the treatment room.

There are more within-group differences than between-group differences so we could never represent, nor ask our clients to represent the entirety of the people in any of the marginalized groups they claim as their own. We should not even assume if we share one identity with our client that we both have the same experiences within this group. Rather, we have to ask questions, learn to be an ally, and consider how our own biases get in the way. Becoming an intersectional therapist is part of the antidote to the fear. This is a continual process requiring much self-reflection and requires a bold look at what parts of your own background show up in your work. We need to know the privileges we have and where we fall into a marginalized space; being a white lesbian is a good example of the privileged/marginalized statuses one person can hold. For me, this has meant being asked by another practitioner, why I wear mascara and think I can call myself a true lesbian. This question was posed many years ago during a conference on treating women with a feminist lens and when I was newly out as a lesbian. I felt confronted and unclear as to what her true agenda was, but it was a generalization about what it means to be a lesbian in the eyes of this beholder and my failure to conform.

What does this all mean in practice? Let me pose a few preliminary questions for you to consider. Are your preferred pronouns clearly stated on your prewritten email signature? If you treat people who may speak a different first language, does your website address this? Is your paperwork available in all languages in which your treatment center is proficient? Do you have magazines in languages representing all non-English speakers who make their way into your waiting room? Do you clearly say whom you treat in your brochures and on webpages? A recent search of ED sites predominantly featured pictures of thin, white, cis-gendered, millennial-aged, female clients. Immediately people of color, men, transgender clients, older people, clients in bigger bodies, and clients who wear religious clothing are left to wonder if they would be accepted in the treatment setting. We lose a lot of clients right there via our social media presence. Even more concerning is the implication that many people struggling will never seek treatment due to feared discrimination and exclusion. Since many centers have begun to expand their inclusion policies, we are on the right path. These slights are fixable and begin the process of welcoming everyone right from the start. In fact, many of the marginalized groups I have listed are doing their own grassroots efforts to help each other as well. One way to challenge yourself and become an ally is to join one of these efforts. A great example of this is T-FFED (Trans Folks Fighting ED’s), an online support community for a population showing a high rate of Eating Disorders.

Harder to address are the ways we practice or things we say. I am a huge proponent of making yourself vulnerable in order to learn. If you find yourself in a position of privilege or are struggling to empathize with the experience of being a minority, volunteer in a place where you become the minority and learn while offering your services. Choose to go into spaces that you are unfamiliar with and feel what that experience is like. Go to a religious service (even if you are a non-practicing person) that is different from what you know and see how that feels. Even better, learn to connect with the experiences you have already had or have regularly in which you are disadvantaged or disenfranchised. Though we will never know what it is like to live as someone other than ourselves, our own experiences are our best guide for empathizing and treating others with respect.

How do we live this as practitioners? We consider that clients with eating disorders or body image struggles are living with a more nuanced group of issues than we might typically consider. We know that some marginalized groups have a higher rate of ED (Transgender Men, Gay Men, Lower SES black women and girls, for example) and we aim to get the people we know are suffering into our offices. When they show up, we learn about what they need by understanding how their identity (or multiple identities) has impacted their relationship with their body. A client who has been a victim of a hate crime, for example, could manifest a desire to control and protect their body with rules and regulations that help reduce anxiety. I often start by challenging what the client is telling me in their story and what they are not. On the other hand, it is important that we don’t assume a client is struggling with a marginalized identity and focus on that with assumptions that may be false. We ask how their gender, sex, socioeconomic status, race, religion, etc. manifests in the ED and their body image. In addition to asking this of our clients who are actively struggling, we must also ask ourselves what role our own sex, gender, race, or religion has played in our life with regard to our body image and our own body. As therapists, we ask ourselves if we have felt safe or unsafe in certain places, conditions, or with certain people and why. Every client who presents, generates my own self-examination of my own biases (positive and negative). What was I raised thinking about members of the group this client belongs to is a frequent question of mine. My own microaggressions are at the start of what I will work on – what happens in the groups, the program, and society follows from self-examination and leads to progress and change.

I recently started to work with a client of Irish-Catholic descent. This client is gender-fluid, 36 years old, has a two-decade Binge-Purge history, is part of the Health at Every Size Movement, but struggles with believing that about themselves, their pronouns are they/their/theirs, they are a transplant to the area so their support system is small and they have a history of hospitalizations for depression. Having been raised with Irish-Catholic friends influenced my early belief system that the families are large, they laugh a lot, the fathers drink a lot, the moms defer outside work to raise the family, they go to church weekly, and they don’t accept gender and sexuality differences well. Further, my experiences working with gender-fluid clients, has told me that their families are not accepting. My client has an accepting loving family with one sibling who is a priest. Their mom died when they were sixteen and their dad is a dentist. There goes my story! The secret of intersectional work is not to have no biases, it is to own whatever biases you have, to explore them outside of the therapy room, and not to allow them to remain in a dark corner whispering “truths” that guide your clinical work. My work is to own my biases and allow them to be just that, a story line I held based on my own limited experience that does not necessarily transfer to my work with this new client. For me, the idea that my biases and prejudices come from fear and early training allows them to become narratives I can reduce to just that – stories, not facts. I also make it a practice to point out when other providers might be working from their own beliefs that could hamper their work with a client.

Another client I’ve recently begun work with is a bi-racial, 29 year-old transgender man struggling with anorexia who also has a history of rape. He has an African American mom who is the primary earner for the family and a white dad who coaches high school sports. Both parents are uncomfortable with their daughter becoming their son and have allowed him to languish in shelters, withdrawn all money (the currency of love in their family), and demanded he reconsider his choice. My client feels misunderstood and scared. He identifies as a Black male, knows he has lost family, runs a risk of being discriminated against and assaulted as a Trans person, and is at higher risk of being unsafe in the world both as transgender and Black. Again, I search my own biases here. There are plenty. I own my privilege as a white, cis-gendered woman and claim connection to my client as I am a lesbian. However, I assumed his sexual preference was gay without asking and I noticed I was ascribing my queer sexuality to him. Further, I know that transitioning is a process with many legs and not everyone conforms to my image of what the physical, emotional, and spiritual changes will be or are currently at when I meet them.

What do I do with my biases in the room? As all therapists, I quietly consider what to say. Sure, I don’t say things that are aggressive and assumptive. But, what I may do inadvertently is not know how to ask what all of these above descriptors mean to both of these clients and how it played out in their eating disorder. I know the story of each of these clients is written firmly in and on the fiber of their being. I also know that each is in a long pattern, well past the stage of an easy fix for their eating disordered symptoms and their readiness to heal is driving on the same road as how safe they feel with me and in the community. Client number one had been in a residential program but they felt unsafe being a larger, gender fluid person in the program they entered. Another client in group therapy suggested they were so lucky they could eat what they wanted and didn’t care what they looked like because men have more freedom to be fat. It was less the other client’s statement and more the lack of response from the therapist who, I was told, said nothing. I know as you read this, you know you are not the person who would allow that, but I have heard it too many times to think at least one of us might have done this. And, I don’t judge us. I am suggesting we explore our thoughts on what might have happened if this were us on a bad day and we weren’t on our A game. However, if you were the therapist who missed this and realized it later, would you feel free to share in your consultation group? I hope you would, even if it is not PC to have any size biases in the ED community, we know they exist and, once aired, we see what we are bringing to the table.

Client two told me about a program that responded poorly to his Trans status. The program he attended before transitioning wanted him on the women’s dorm. His clarity by age 12 of being male had been stigmatized in his family, school and, in his mind, now in treatment. He was bullied and was afraid to be himself his whole life and expected his gender identity to be recognized in residential care. The program explained to him that his male identity was secondary to the placement because he still had a vagina that “qualified” him to be part of the women’s unit. They said this with a pronouncement of what they considered concern for his safety (which also brings a lot of questions to the forefront about what was considered unsafe in housing him with men). He did not stay. This story reminded me of taking my child to look at a private school that everyone raved about and having them tell me they “knew how to handle gay kids.” While my child has two moms, we did not assume anyone would believe she was gay. That is a perfect example of a microaggression, as was the vagina comment that was not meant to turn anyone away.

The subtleties of safety that continually are demonstrated by hate crime statistics also further our need to educate ourselves and show up as true allies. Dr. Sue calls this “knowing” the client’s experiential reality. Following is one example of not treating everyone who needs ED therapy. Could we call it a microaggression to fail to reach out to financially challenged communities about ED’s when the people living there cannot afford the treatment? New studies tell us that, for example, Bulimia is on the rise in young African American girls from under-resourced, poor communities. The Goeree Study (2008) demonstrated that Black girls from a lower SES (2300 girls) had a 50% greater likelihood of developing Bulimia than the White girls in the study. Is the ED community doing outreach to work with these girls? Working with your organization or office to offer sliding scales and to accept a variety of insurances are a few ways to become active allies. How can we treat all clients who deserve and require our help with the resource restrictions that exist? And, while money helps get an individual into treatment, being underrepresented or mistreated by clinicians in the treatment setting can also be harmful. The barriers to recovery due to identity or marginalized status are not overcome simply by accessing treatment.

As we know, microaggressions show up with even the best-intentioned people and there is plenty of work to be done via introspection as well as outreach. Questions to ask yourself and then discuss in a supervision group are listed below. Dr. Sue has some great recommendations for being an ally. If you witness a microaggression speak up. Don’t just cringe inside. Ask yourself questions such as what did I learn about sexuality and my own body growing up and how does that show up in the room with clients? Keep your defensiveness at an all time low when challenged by a client who tells you about something you said that was misinformed. This is not about knowing, it is about being present. There is no right or wrong and it is not a test. It is about showing up. Be willing in your consultation groups to discuss your biases and how they might have played a part in a case or as you led a group. Don’t witness discrimination without speaking up – as clinicians, we don’t have the right to be silent.

Have The Conversation:

*How does social justice fit into my view of therapy?

*Do I know the cultural norms around food and body image that each client I work with carries with them?

*What did I learn about gender and sex as a child?

*What did I learn about sexual preferences and what do I know now?

*What is my view of a healthy body?

*Do different sizes of bodies affect me in any way?

*What do I understand about first generation clients and their struggle between eating norms in their current environment and what their family expects from them at home?

*Do I ask my clients how their racial, sexual, ethnic identity is linked to body image and their eating disorder?

*Was I raised believing that a body is meant to be functional and strong or beautiful and presentable?

*What social privileges do I have?

*When did I last stand up as an ally when I saw an injustice at work?

About the author:

Dr. Robin Hornstein, Ph.D, has been a Licensed Psychologist for over 30 years. Prior to that she completed a degree in Early Childhood Education and worked with young children. She is a Certified Integrative Health Coach as well. Earning a doctorate from the Counseling Psychology program at Temple University, Robin spent many years serving clients in residential recovery before entering private practice. She is the co-founder and Clinical Director of Hornstein, Platt and Associates, an insurance based practice comprised of therapists, psychiatrists and wellness practitioners with offices in Philadelphia and local suburbs. Robin specializes in working with people recovering from Eating Disorders and Trauma, Women’s Issues and the LGBTQ communities and conducts trainings, writes and provides supervision in these areas. A true believer in self-care, Robin practices Yoga, journals, meditates and walks with her dog.